Laparoscopic Paraesophageal Hiatus Hernia Repair

  • Philip W. Carrott Jr.
    Address reprint requests to Philip W. Carrott, Jr., MD, Department of Surgery, Section of Thoracic Surgery, University of Michigan Health System, 2120N Taubman Center/5344, 1500 E. Medical Center Dr. Ann Arbor, MI 48109.
    Department of Surgery, Section of Thoracic Surgery, University of Michigan Health System, Ann Arbor, MI
    Search for articles by this author
Open ArchivePublished:March 26, 2014DOI:
      For a benign condition, paraesophageal hiatal hernia (PEH) is the source of considerable controversy in the minimally invasive surgery and thoracic surgery literature. Controversies exist as to who should undergo repair, how the repair should be performed, and what the natural history is for asymptomatic patients. The first repairs performed by Collis and others in the 1950s began as a thoracoabdominal approach, and Dr Belsey perfected his repair via left thoracotomy. The open abdominal approach was also widely used and studied by a number of centers and includes the Hill repair, popularized by Dr Lucius Hill in Seattle, WA. The use of laparoscopy to repair paraesophageal hernias began with the first laparoscopic cases in the early 1990s. Since then, it has become an accepted or even preferred method to repair uncomplicated paraesophageal hernias.
      The advantages of laparoscopy are well known, including shorter hospital stays, reduced postoperative pain, faster return to normal activity, and avoidance of lengthy abdominal or thoracic incisions as well as their attendant complications of chronic pain, incisional herniation, pneumonia, etc. As of 2011, more than 70% of all diaphragmatic hernia repairs were performed laparoscopically, according to the National Inpatient Sample (; Data Partners: The median length of stay was 2 days vs 7 and 6 days for open abdominal and thoracic repairs, respectively. The difficulty with the laparoscopic repair is an increased recurrence rate of 10%-40% over that of repairs that anchor the stomach and the esophagogastric junction (EGJ) in the abdomen, for example, the Belsey Mark IV repair or the Hill repair. The National Inpatient Sample documented more than 10,000 laparoscopic paraesophageal hernia repairs in 2011, more than 7000 in 2010, and more than 6000 in 2009.
      These numbers likely include both thoracic and laparoscopic surgical procedures and possibly procedures performed for PEH and bariatric indications. At any rate, this population is increasing and more patients are presenting for repair. In an analysis of the New York inpatient population, as more repairs were carried out, fewer patients were presenting emergently.
      • Polomsky M.
      • Hu R.
      • Sepesi B.
      • et al.
      A population-based analysis of emergent vs elective hospital admissions for an intrathoracic stomach.
      The emergent population has a higher morbidity and mortality rate, has a longer length of stay, and likely is associated with higher costs to the health care system. In a population from Virginia Mason Medical Center in Seattle, WA, we found that almost all patients presented with a symptomatic paraesophageal hernia, and most of these were symptomatically improved following repair. The symptoms frequently associated with paraesophageal hernias include reflux, regurgitation, early satiety, dysphagia, chest or abdominal pain, shortness of breath, anemia, and various other symptoms related to these, such as modifications of eating habits, avoiding late meals, and postprandial difficulties. We also found that certain symptoms were associated with the degree of herniation: smaller hernias were associated with heartburn and regurgitation, hernias with 50%-75% of the stomach herniated were associated with anemia, and the largest hernias were associated with dyspnea, early satiety, and decreased meal size.
      • Carrott P.W.
      • Hong J.
      • Kuppusamy M.
      • et al.
      Clinical ramifications of giant paraesophageal hernias are underappreciated: Making the case for routine surgical repair.
      • Carrott P.W.
      • Markar S.R.
      • Hong J.
      • et al.
      Iron-deficiency anemia is a common presenting issue with giant paraesophageal hernia and resolves following repair.
      The laparoscopic paraesophageal hernia repair has evolved over time, and experts in the field recently weighed in on various modifications to reduce the rate of recurrence. The use of a mesh was studied in a landmark article from the University of Washington, and it was found to not reduce the rate of recurrence in long-term follow-up and to cause problems such as erosion into the esophagus, which has been reported with both the GORE-TEX and polypropylene meshes. More recently, surgeons have used relaxing incisions in the diaphragm to reduce tension on the crural closure. The diaphragm may then be closed with a mesh away from the esophagus, which prevents complications from mesh erosion. Dr Demeester described a number of refinements to minimize recurrence in a recent article.
      • DeMeester S.R.
      Laparoscopic paraesophageal hernia repair: Critical steps and adjunct techniques to minimize recurrence.
      The group at Swedish Medical Center in Seattle has also described their laparoscopic Nissen-Hill repair, which uses the antireflux attributes of the Nissen operation with the anchoring sutures of the Hill repair.
      • Qureshi A.P.
      • Aye R.W.
      • Buduhan G.
      • et al.
      The laparoscopic Nissen-Hill hybrid: pilot study of a combined antireflux procedure.
      The basic outline of an uncomplicated laparoscopic PEH repair is described in the following section. In my experience, even hernias encompassing 100% of the stomach can be repaired laparoscopically, although it should be emphasized that if one is not making progress in excising the sac, or there is difficult anatomy that is not seen well enough, conversion to a laparotomy or a thoracotomy should be performed without hesitation.
      The steps of the operation are as follows: (1) division of the gastrohepatic ligament to the diaphragm, (2) entry into the plane outside the hernia sac either at the point of attachment of the gastrohepatic ligament to the diaphragm or along the medial edge of the right crus, (3) reduction of the hernia sac and its contents into the abdomen, (4) identification of the esophagus and the vagus nerves, (5) division of the short gastric arteries, (6) excision of the hernia sac and determination of esophageal length, (7) performance of a lengthening procedure if needed, (8) closure of the crura, and (9) fundoplication with fixation of the wrap to the diaphragm or the crura. For any paraesophageal hernia repair, the essentials are reduction and excision of the sac, determination of esophageal length, crural closure, and fixation of the EGJ or fundoplication.
      Laparoscopic equipment used for most procedures should be adequate for a paraesophageal hernia repair. I do prefer to use the 45° laparoscope, and typically use the 10-mm version, principally because my preferred entry method is with an optical or “view” trocar, where one visualizes each layer of the abdominal wall while entering the abdomen (one must use a 0° scope with these trocars). The ability for the 45° scope to visualize around corners is essential in this challenging location. As detailed in Figure 1, the camera port is placed just to the left of midline at 15 cm from the xiphisternum. Another trocar of 11 or 12 mm is used as the left upper quadrant trocar, approximately 12 cm from the xiphisternum, close to the costal margin. The larger trocar is used in case a Collis gastroplasty is needed, as described later, to accommodate the Endo GIA stapler. It should be 4 fingerbreadths or 8-10 cm from the camera port. Other 5-mm trocars are also placed at least 8-10 cm apart, 1-2 in the right upper quadrant and 1 lower on the left flank. We use the Nathanson liver retractor, which is placed at the xiphisternum with a 5-mm trocar, making the fascial track for this instrument, the trocar is replaced by the liver retractor and it may then be used in another location (Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9).
      Figure thumbnail gr1
      Figure 1The ports we use include the following: (1) an optical trocar (12 mm) to gain access to the abdomen, typically at 15 cm from the xiphisternum just to the left of midline; (2) a left upper quadrant trocar (11-12 mm) for the working port, typically 12 cm from the xiphisternum along the costal margin with the abdomen desufflated; (3) a left flank 5-mm trocar for retraction by the assistant; (4) 1 or 2 right upper quadrant trocars of 5 mm for the surgeon, depending on the degree of difficulty retracting intra-abdominal contents; and (5) a liver retractor port, our preferred retractor is the Nathanson liver retractor that is placed at the xiphisternum. Additional ports may be needed in the case of a large stomach or difficult dissection. We routinely use 2 ports on the patientʼs right if the dissection is difficult around the greater curve or if the stomach is large. These ports must be spaced appropriately, 8-9 cm apart to avoid “fencing” during the procedure.
      Figure thumbnail gr2
      Figure 2The procedure starts with incision of the gastrohepatic ligament, where you can see through it. Carry this up to the hiatus, taking care to note any replaced hepatic arteries that may be in this area. The peritoneum should be incised at the hiatus, along the right crus, preserving the peritoneum on the crura. The hernia sac is then retracted into the abdomen and the plane is developed between the sac and the mediastinum. The right pleura is encountered here and is frequently entered, which is rarely of any clinical consequence. Replaced left hepatic arteries are also encountered in this first step and may be preserved at the surgeonʼs discretion.
      Figure thumbnail gr3
      Figure 3Dissection is continued with blunt maneuvers and energy source (we prefer the harmonic scalpel device because of the potential for injury to the vagus nerves), breaking up the flimsy adhesions between the hernia sac and the mediastinum. This portion of the procedure is the most variable, but the following goals remain: (1) removal of the sac from the mediastinum, (2) avoiding injury to the esophagus, and (3) mobilization of the esophagus to correct esophageal shortening.
      Figure thumbnail gr4
      Figure 4Dissection of the left crus can be accomplished by coming around from the right or by coming up from the greater curvature of the stomach. Typically, it is easier to perform this after dividing the short gastrics. The stomach and the omentum can be sizable in some patients, and this may necessitate the placement of additional trocars so as to provide appropriate exposure. The greater curvature of the stomach is mobilized from the bare area to the hiatus. Once the hernia sac is reduced into the abdomen, the stomach would be largely intra-abdominal. Retraction of the stomach is not necessary during reduction of the hernia sac into the abdomen. At this point, the stomach and the esophagogastric junction (EGJ) should be completely mobilized with the mediastinal attachments taken circumferentially as far as one can see into the hiatus.
      Figure thumbnail gr5
      Figure 5We routinely remove the hernia sac and the esophageal fat pad to both prevent recurrence and see anatomical landmarks, allowing construction of an antireflux fundoplication. Once the hernia sac is removed, one should reconstruct the hiatus and assess where the EGJ would be following repair. During removal of the sac, be conscious of the path of the vagus and the left gastric or gastroepiploic artery, these structures are surprisingly easy to injure if excision of the sac is started too close to the stomach. The Maloney dilator may be helpful in outlining this anatomy if there is any question as to where the esophagus or the vagus nerves are located in relation to the sac. We start closing the hiatus posteriorly, and occasionally we need to close it anteriorly as well in the case of large hernias. As the hiatus is closed, we use a Maloney dilator (54-58 F) to assess the size of the hiatal opening. It is closed too tightly if the tip of a grasper cannot be admitted into the hiatus with the dilator in place. n = nerve.
      Figure thumbnail gr6
      Figure 6If 2 cm of intra-abdominal esophagus is not available, we prefer the wedge fundectomy as the lengthening procedure. This can preserve much of the fundus of the stomach if one divides high on the fundus, stapling toward the lesser curve and the edge of the dilator with a 60-mm thick tissue Endo GIA stapler. Usually only 1 firing is required to reach the dilator. Another firing of the stapler is then used to complete the wedge alongside the dilator toward the hiatus.
      Figure thumbnail gr7
      Figure 7We start closing the hiatus posteriorly, and occasionally we need to close it anteriorly as well in the case of large hernias. As the hiatus is closed, we use a Maloney dilator (54-58 F) to assess the size of the hiatal opening. It is closed too tightly if the tip of a grasper cannot be admitted into the hiatus with the dilator in place. n = nerve.
      Figure thumbnail gr8
      Figure 8At this point, an antireflux fundoplication is needed to both prevent reflux and impede reherniation. A complete or near-complete wrap fundoplication (Nissen/360° or Toupet/270°) is used if we do not need a lengthening procedure. Otherwise, we prefer an anterior partial fundoplication (Dor/180°) to keep tension off the fresh staple line of the wedge fundectomy, although we are finding anecdotally that recurrence is reduced if a partial wrap that includes a posterior component is used, either Nissen or Toupet, which can buttress the hiatus and prevent cephalad movement of the EGJ.
      Figure thumbnail gr9
      Figure 9The wrap is then anchored to the crural repair or the diaphragm to prevent reherniation and recurrence. The Hill repair is an alternative method for anchoring the EGJ to the crura or the preaortic fascia, which has a low recurrence rate and can offer stability to the difficult problem of recurrence, particularly in those patients with a large hiatal defect. This method of anchoring the EGJ also likely improves esophageal function as the esophagus can be under some mild tension, which is necessary for normal peristalsis.


      This procedure, once one gains experience, can reliably reduce uncomplicated PEHs with good results and minimal surgical trauma to the patient. The reherniation rate is not insignificant, but measures may be taken as one gains experience with this technique, to minimize recurrences. At a tertiary care center, one would see more recurrences from physicians who may not have closed the hiatus as carefully or who did not anchor the stomach to the diaphragm. The usual Nissen fundoplication, if not anchored intra-abdominally, is actually more likely to reherniate as the stomach is wrapped around the esophagus, making it more conducive to slipping into an incompletely closed hiatus. This population may initially lose weight, but one of the reasons patients develop large paraesophageal hernias is that their intra-abdominal pressure is increased from obesity. Once their alimentary tract is normally configured, they are able to eat without symptoms, allowing unhindered weight gain. I advise patients to watch for this, as increased weight also leads to an increased opportunity for recurrence.
      Thoracic surgeons are gaining more experience with laparoscopic techniques, as outlined earlier, and the experience gained in laparoscopic paraesophageal hernia repairs can lead to better outcomes with other minimally invasive techniques, such as minimally invasive esophagectomy. Experience gained in terms of the esophageal lengthening or hiatal closure should lead to better outcomes and less recurrences over time. This notoriously difficult area is more easily dealt with laparoscopically for both the patient and the surgeon, if the anatomy is straightforward. Larger hernias with colon and stomach in the chest or hiatal openings that are difficult to close without undue tension should be converted to or started as an open operation, ideally through the left chest. The insufflation puts more tension on the hiatus and the diaphragm, making the dissection easier but the closure more difficult.
      As the anatomy can be quite variable, it is of upmost importance to fastidiously look at the anatomy and reorient oneself when the vagus, left gastric artery, esophagus, and stomach are in view and while either dissecting or excising the hernia sac. Injury to one or more of these structures by an absent-minded surgeon has caused a number of poor outcomes that have led to patients being left with a fistula, or worse, in discontinuity. Usually one can bring down the EGJ to below the hiatus, but if there is any tension, a gastroplasty should be performed. In addition, outcomes are likely to be improved the more securely the wrap is anchored in the abdomen, either to the crural repair or to the diaphragm. The anchored Toupet, Hill, or Nissen repairs performed over a dilator should have equivalent recurrence rates but may vary with the amount of residual reflux. It is the advantage of laparoscopy, especially in the era of “high-definition” video endoscopy, that one is able to more easily visualize the relevant anatomy and produce a durable repair to improve patient outcomes.